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World Journal of Gastroenterology Oct 2008Pancreatic resection is the treatment of choice for pancreatic malignancy and certain benign pancreatic disorders. However, pancreatic resection is technically a... (Review)
Review
Pancreatic resection is the treatment of choice for pancreatic malignancy and certain benign pancreatic disorders. However, pancreatic resection is technically a demanding procedure and whereas mortality after a pancreaticoduodenectomy is currently < 3%-5% in experienced high-volume centers, post-operative morbidity is considerable, about 30%-50%. At present, the single most significant cause of morbidity and mortality after pancreatectomy is the development of pancreatic leakage and fistula (PF). The occurrence of a PF increases the length of hospital stay and the cost of treatment, requires additional investigations and procedures, and can result in life-threatening complications. There is no universally accepted definition of PF that would allow standardized reporting and proper comparison of outcomes between different centers. However, early recognition of a PF and prompt institution of appropriate treatment is critical to the prevention of potentially devastating consequences. The present article, reviews the evolution of post resection pancreatic fistula as a concept, and discusses evolving definitions, the current preventive strategies and the management of this problem.
Topics: Gastrostomy; Humans; Ligation; Pancreatectomy; Pancreatic Ducts; Pancreatic Fistula; Pancreaticojejunostomy; Reoperation; Stents; Surgical Stapling; Suture Techniques; Terminology as Topic; Treatment Outcome
PubMed: 18855976
DOI: 10.3748/wjg.14.5789 -
Journal of Hepato-biliary-pancreatic... 2008Postoperative pancreatic fistula (POPF) is the most common major complication after pancreatoduodenectomy (PD) and it can lead to prolonged hospital stay, increased... (Review)
Review
Postoperative pancreatic fistula (POPF) is the most common major complication after pancreatoduodenectomy (PD) and it can lead to prolonged hospital stay, increased costs, and mortality. The POPF rate is strictly correlated to the definition applied, but there are so many different definitions in the literature that comparison between published series of patients is difficult. The International Study Group of Pancreatic Fistula (IGSPF) has developed a new definition, with a grading system able to stratify complicated patients into three groups, based upon the clinical implications and costs of their postoperative course. The most important risk factors identified are a soft pancreatic texture and a main pancreatic duct diameter of 3 mm or less. Several surgical techniques have been studied in order to prevent anastomotic leakage, but none has been demonstrated to be superior to others. The use of somatostatin analogues is still matter of controversy. Conservative management of POPF is usually effective, but in patients with deteriorating clinical status with evidence of sepsis, surgical management is needed.
Topics: Humans; Pancreatic Fistula; Postoperative Complications; Risk Factors
PubMed: 18535760
DOI: 10.1007/s00534-007-1301-y -
Surgery Jan 2010Pancreatic-pleural fistula is an uncommon complication of chronic pancreatitis occurring as a result of disruption of the main pancreatic duct and tracking of pancreatic... (Review)
Review
BACKGROUND
Pancreatic-pleural fistula is an uncommon complication of chronic pancreatitis occurring as a result of disruption of the main pancreatic duct and tracking of pancreatic fluid through the retroperitoneum into 1 or both thoracic cavities. The optimal treatment strategy for pancreatic-pleural fistula is unknown; it has traditionally been medical management followed by operative therapy for patients who fail to respond to conservative treatment. Our objective was to compile the case reports of pancreatic-pleural fistula in the literature in order to better define clinical management strategy.
METHODS
The case management of pancreatic-pleural fistula was reviewed and a structured MEDLINE search for published studies was performed. Descriptive statistical analysis was performed on compiled data.
RESULTS
Review of the literature revealed 63 adult patients with pancreatic-pleural fistula published in English between 1970 and 2008. The majority of patients were male (71%) and there was a predominance of alcohol-associated chronic pancreatitis (51%). There were 10 complications (16%) and 2 deaths (3%) reported. Most patients were treated initially with medical therapy (87%). Medical therapy was deemed to have failed after an average period of 35+/-5 days. Total duration of therapy for patients in whom operative intervention was required after attempted medical management was 40+/-6 days, which was greater than the surgery alone cohort. In total, operative treatment was successful more often than medical therapy (94% vs 31%).
CONCLUSION
Analysis from this series indicates that a majority of patients recover from pancreatic-pleural fistula without sequelae (81%). Attempts at prolonged periods of medical therapy tend to delay the resolution of the fistula compared with patients who undergo definitive operative intervention early in the course of treatment.
Topics: Adult; Female; Humans; Lung Diseases; Pancreatic Fistula; Pleural Diseases
PubMed: 19744435
DOI: 10.1016/j.surg.2009.03.024 -
HPB : the Official Journal of the... Sep 2021Preoperative chemo- or chemoradiotherapy is recommended for borderline-resectable pancreatic cancer. The aim of this study was to determine the impact of preoperative... (Meta-Analysis)
Meta-Analysis Review
The effect of preoperative chemotherapy and chemoradiotherapy on pancreatic fistula and other surgical complications after pancreatic resection: a systematic review and meta-analysis of comparative studies.
BACKGROUND
Preoperative chemo- or chemoradiotherapy is recommended for borderline-resectable pancreatic cancer. The aim of this study was to determine the impact of preoperative therapy on surgical complications in patients with resected pancreatic cancer.
METHODS
This systematic review and meta-analysis included studies reporting on the rate of surgical complications after preoperative chemo- or chemoradiotherapy versus immediate surgery in pancreatic cancer patients. The primary endpoint was the rate of grade B/C POPF. Pooled odds ratios were calculated using random-effects models.
RESULTS
Forty-one comparative studies including 25,389 patients were included. Vascular resections were more often performed after preoperative therapy (29.4% vs. 15.7%, p < 0.001). Preoperative therapy was associated with a lower rate of grade B/C POPF as compared to immediate surgery (pooled OR 0.47, 95%CI 0.38-0.58). This reduction was mostly obtained by preoperative chemoradiotherapy (OR 0.46, 95%CI 0.29-0.73), but not by preoperative chemotherapy alone (OR 0.83, 95%CI 0.59-1.16). No difference was demonstrated for major morbidity, mortality, postpancreatectomy haemorrhage, delayed gastric emptying and overall morbidity.
CONCLUSION
Preoperative chemo- and chemoradiotherapy in patients with pancreatic cancer appears to be safe with respect to POPF and other surgical complications as compared to immediate surgery. The reduced rate of POPF appears to be attributable to preoperative chemoradiation.
Topics: Chemoradiotherapy; Humans; Neoadjuvant Therapy; Pancreatectomy; Pancreatic Fistula; Pancreatic Neoplasms; Postoperative Complications
PubMed: 34099372
DOI: 10.1016/j.hpb.2021.04.027 -
The Journal of Surgical Research Dec 2022Development of clinically relevant postoperative pancreatic fistula (CR-POPF) in adult splenectomies following trauma occur in 1%-3% of cases. We hypothesized that the...
INTRODUCTION
Development of clinically relevant postoperative pancreatic fistula (CR-POPF) in adult splenectomies following trauma occur in 1%-3% of cases. We hypothesized that the use of sutures in splenic hilum ligation compared to staples was associated with a reduced rate of CR-POPF incidence.
METHODS
Adult trauma patients (age ≥17 y) that underwent nonelective splenectomy from 2010 to 2020 were retrospectively evaluated from the trauma registries of all three adult level 1 trauma centers in Indiana. Patients were excluded if they were pregnant, currently incarcerated, expired within 72 h of admission, or had a pancreatic injury diagnosed preoperatively or intraoperatively. A Firth logistic regression using a penalized-maximum likelihood estimate for rare events was used for univariate predictive modeling (SPSS 28.0) of surgical technique on CR-POPF development.
RESULTS
Four hundred nineteen adult splenectomies following trauma were conducted; 278 were included. CR-POPF developed in 14 cases (5.0%). Sutures alone were used in 200 cases: seven developed CR-POPF (3.5%). Staples alone or in combination with sutures were used in 74 cases: seven developed CR-POPF (9.5%). There was no statistically significant difference between the use of sutures alone compared to the use of staples alone (P = 0.123) or in combination (P = 0.100) in CR-POPF incidence.
CONCLUSIONS
Our 10-y retrospective review of CR-POPF finds the complication to be rare but morbid. This study was underpowered to show any difference in surgical technique. However, we do propose a new institutional norm that CR-POPF develop in 5% of splenectomies after trauma and conclude that further study of optimal technique for emergent splenectomy is warranted.
Topics: Humans; Adult; Pancreatic Fistula; Splenectomy; Retrospective Studies; Likelihood Functions; Risk Factors; Postoperative Complications; Pancreaticoduodenectomy
PubMed: 35952555
DOI: 10.1016/j.jss.2022.07.005 -
ANZ Journal of Surgery May 2021Many studies have explored factors relating to post-operative pancreatic fistula (POPF); however, the original definition (All-POPF) was revised to include only... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Many studies have explored factors relating to post-operative pancreatic fistula (POPF); however, the original definition (All-POPF) was revised to include only 'clinically relevant' (CR) POPF. This study identified variables associated with the two International Study Group on Pancreatic Surgery definitions to identify which variables are more strongly associated with CR-POPF.
METHODS
A systematic review identified all studies reporting risk factors for POPF (using both International Study Group on Pancreatic Fistula definitions) following pancreatoduodenectomy. The primary outcome was factors associated with CR-POPF. Meta-analyses (random effects models) of pre-, intra- and post-operative factors associated with POPF in more than two studies were included.
RESULTS
Among 52 774 patients All-POPF (n = 69 studies) and CR-POPF (n = 53 studies) affected 27% (95% confidence interval (CI ) 23-30) and 19% (CI 17-22), respectively. Of the 176 factors, 24 and 17 were associated with All- and CR-POPF, respectively. Absence of pre-operative pancreatitis, presence of renal disease, no pre-operative neoadjuvant therapy, use of post-operative somatostatin analogues, absence of associated venous or arterial resection were associated with CR-POPF but not All-POPF.
CONCLUSION
In conclusion this study demonstrates wide variation in reported rates of POPF and that several risk factors associated with CR-POPF are not used within risk prediction models. Data from this study can be used to shape future studies, research and audit across ethnic and geographic boundaries in POPF following pancreatoduodenectomy.
Topics: Humans; Pancreas; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Risk Factors
PubMed: 33135873
DOI: 10.1111/ans.16408 -
Journal of Gastroenterology and... May 2023
Review
Gastrointestinal: Corroded gastric wall due to pancreatic fistula after pancreaticogastrostomy relieved by endoscopic ultrasound-guided transluminal pancreatic duct drainage.
Topics: Humans; Pancreatic Fistula; Pancreas; Endosonography; Pancreatic Ducts; Drainage; Ultrasonography, Interventional
PubMed: 36219498
DOI: 10.1111/jgh.16014 -
Journal of Gastrointestinal Surgery :... Jan 2009Despite significant improvements in the safety and efficacy of pancreatic surgery, post-operative pancreatic fistulae remain an unsolved dilemma. These occur when the... (Review)
Review
Despite significant improvements in the safety and efficacy of pancreatic surgery, post-operative pancreatic fistulae remain an unsolved dilemma. These occur when the transected pancreatic gland, pancreatic-enteric anastomosis, or both, leak rendering the patient at significant risk. They are especially important today since indications for resection (IPMN, carcinoma) continue to increase. This review considers definitions and classifications of pancreatic fistulae, risk factors, preventative approaches and offers management strategies for when they do occur. Key citations from the past seventeen years have been scrutinized, and together with personal experience, provide the basis for this review.
Topics: Humans; Incidence; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Care; Risk Factors
PubMed: 18496727
DOI: 10.1007/s11605-008-0534-7 -
Surgery Feb 2023Early stratification of postoperative pancreatic fistula according to severity and/or need for invasive intervention may improve outcomes after pancreaticoduodenectomy....
BACKGROUND
Early stratification of postoperative pancreatic fistula according to severity and/or need for invasive intervention may improve outcomes after pancreaticoduodenectomy. This study aimed to identify the early postoperative variables that may predict postoperative pancreatic fistula severity.
METHODS
All patients diagnosed with biochemical leak and clinically relevant-postoperative pancreatic fistula based on drain fluid amylase >300 U/L on the fifth postoperative day after pancreaticoduodenectomy were identified from a consecutive cohort from Birmingham, UK. Demographics, intraoperative parameters, and postoperative laboratory results on postoperative days 1 through 7 were retrospectively extracted. Independent predictors of clinically relevant-postoperative pancreatic fistula were identified using multivariable binary logistic regression and converted into a risk score, which was applied to an external cohort from Verona, Italy.
RESULTS
The Birmingham cohort had 187 patients diagnosed with postoperative pancreatic fistula (biochemical leak: 99, clinically relevant: 88). In clinically relevant-postoperative pancreatic fistula patients, the leak became clinically relevant at a median of 9 days (interquartile range: 6-13) after pancreaticoduodenectomy. Male sex (P = .002), drain fluid amylase-postoperative day 3 (P < .001), c-reactive protein postoperative day 3 (P < .001), and albumin-postoperative day 3 (P = .028) were found to be significant predictors of clinically relevant-postoperative pancreatic fistula on multivariable analysis. The multivariable model was converted into a risk score with an area under the receiver operating characteristic curve of 0.78 (standard error: 0.038). This score significantly predicted the need for invasive intervention (postoperative pancreatic fistula grades B3 and C) in the Verona cohort (n = 121; area under the receiver operating characteristic curve: 0.68; standard error = 0.06; P = .006) but did not predict clinically relevant-postoperative pancreatic fistula when grades B1 and B2 were included (area under the receiver operating characteristic curve 0.52; standard error = 0.07; P = .802).
CONCLUSION
We developed a novel risk score based on early postoperative laboratory values that can accurately predict higher grades of clinically relevant-postoperative pancreatic fistula requiring invasive intervention. Early identification of severe postoperative pancreatic fistula may allow earlier intervention.
Topics: Humans; Male; Pancreaticoduodenectomy; Pancreatic Fistula; Retrospective Studies; Risk Factors; Risk Assessment; Drainage; Postoperative Complications; Amylases
PubMed: 37530481
DOI: 10.1016/j.surg.2022.09.008 -
Updates in Surgery Dec 2023Postoperative pancreatic fistula (POPF) is a severe complication after distal pancreatectomy (DP); however, it is unclear how to effectively reduce the incidence. The... (Meta-Analysis)
Meta-Analysis Review
Postoperative pancreatic fistula (POPF) is a severe complication after distal pancreatectomy (DP); however, it is unclear how to effectively reduce the incidence. The purpose of this meta-analysis is to determine whether reinforced stapling reduces POPF after DP. From February 2007 to April 2023, a comprehensive search of electronic data and references was conducted in PubMed/Medline, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. In this study, the perioperative outcomes were evaluated for the reinforced stapler (RS) group and the standard stapler (SS) group in DP using Review Manager Software. Using fixed- or random-effects models, pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated. In total, three randomized clinical trials (RCTs) with 425 patients and five observational clinical studies (OCS) with 318 patients were included. In pooled meta-analyses from RCTs, there was no difference between the two groups in the incidence of POPF (OR = 0.79; 95% CI [0.47,1.35]; P = 0.39), intraoperative blood loss (MD = 10.66; 95% CI [- 28.83,50.16]; P = 0.6), operative time (MD = 9.88; 95% CI [- 8.92,28.67]; P = 0.3), major morbidity (OR = 1.12; 95% CI [0.67,1.90]; P = 0.66), reoperation (OR = 0.97; 95% CI [0.41,2.32]; P = 0.95), readmission (OR = 0.99; 95% CI [0.57,1.72]; P = 0.97) or hospital stay (MD = - 0.95; 95% CI [- 5.22,3.31]; P = 0.66). However, the results of POPF and readmission were favorable for RS in the OCS group.
Topics: Humans; Pancreatectomy; Pancreatic Fistula; Pancreas; Postoperative Complications; Reoperation; Risk Factors; Randomized Controlled Trials as Topic
PubMed: 37950142
DOI: 10.1007/s13304-023-01691-5